Open versus laparoscopic liver resection of colorectal metastases: a meta-analysis of matched patient populations

In recent years, the management of colorectal liver metastases (CRLM) has evolved significantly. Laparoscopic liver resection is increasingly being performed, despite a lack of major randomized controlled trial evidence or widespread international consensus. The objective of this review was to compare the short- and long-term outcomes following open and laparoscopic CRLM resection. A systematic review of comparative matched population studies was performed. Evaluated endpoints included surgical outcomes and survival outcomes. Twelve studies were included in this review, reporting on 3095 patients. R0 (negative margins) rates were higher in the laparoscopic CRLM group (89.3% versus 86.9%). In addition, laparoscopic resection was associated with less blood loss (486 mls versus 648 mls, p ≤ 0.0001*) and reduced blood transfusion rates (6.7% vs. 12.2%, OR 2.13, 95% CI 1.08-4.19, p = 0.03*). Major complication rates were higher in the open CRLM group (12.5% vs. 8.1%, OR 1.74, 95% CI 1.30-2.33, p = 0.03*), as was overall hospital length of stay (median 7 versus 5.5 days, p = 0.001*). Perioperative mortality was similar between both groups, and there was no significance in 5-year overall survival for open or laparoscopic CRLM resection groups (58% and 61% respectively). Laparoscopic CRLM resection is associated with less blood loss, lower transfusion rates, major complications, and overall hospital length of stay with comparable oncological outcome.

Mucinous colorectal cancer: Disease characteristics, treatment outcomes and the impact of metastasectomy

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Background: Mucinous colorectal cancer (CRC) differs from adenocarcinoma with regard to clinical and histological features and is reported to have inferior outcomes when compared to non-mucinous CRC. This study aims to evaluate the clinical features and outcomes of patients with mucinous CRC at our institution. Methods: Medical records of patients with CRC that were referred to medical oncology between September 1999 and September 2018 were retrospectively reviewed. Mucinous histology was defined as those containing > 50% mucin identified on histology specimens. Statistical analysis was performed using Prism V9.0. Results: We identified 1,115 patients with CRC that were referred to medical oncology during this period. The tumours of 81 (7.3%) patients were classified as mucinous. Median age was 65 (28-94 years) and 45 (55.5%) were male. Forty-one patients (51%) had right sided tumours, 27 (33%) had left sided tumours and 13 (16%) had rectal tumours. Twenty-three (28.4%) had de novo metastatic disease. Eleven of 24 patients (46%) with stage II disease relapsed and 18 of 33 (55%) of those with stage III disease relapsed. Radiological surveillance identified 20/29 (69%) of relapsed disease, 5 (17%) were symptomatic and 4 (14%) had a rise in CEA. Median follow up for patients with stage II disease was 53 months and 3 year and 5-year disease free survival (DFS) was equal in both groups at 60.9%. For stage III disease 3- and 5-year DFS was 58.1% and 48.4% respectively with a median follow up of 43 months. In the metastatic setting, we observed no significant difference in overall survival (OS) between left and right sided tumours ( p = 0.550). Median OS for pts with stage IV mucinous CRC who received any treatment was 25 months. Metastasectomy was performed in 25/52 (48%) patients and was associated with a significant improvement in OS, 23 vs 51 months ( p < 0.005, HR 0.4). Conclusions: Mucinous CRC has been associated with inferior responses to treatment and worse overall outcomes compared to non-mucinous histologies. Survival in advanced-stage disease in our cohort is higher than what has been reported in the literature. With an effective multi-disciplinary approach and the increasing use of metastasectomy as a treatment option, survival in the advanced disease setting may be comparable to non-mucinous CRC.

Contemporary multi-modal management of colorectal cancer: Evolving patterns of care in an Irish cohort

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Background: The last 15 years have seen significant improvements in the outcomes of patients (pts) with CRC. More effective systemic therapy (Rx) and wider use of surgery (Sx) in stage IV disease (Dx) are key drivers of this. We evaluated the impact of intense surveillance in concert with greater use of metastasectomy and improved systemic Rx on CRC outcomes. Methods: This is a retrospective review of the clinical, radiologic and histological records for consecutive pts with CRC who were referred to the multi-disciplinary CRC team from 2003-2016. Pts with stage I/II Dx were included when referred for adjuvant Rx for high-risk features. We recorded pt characteristics, Rx received and outcomes. Survival was assessed using Kaplan-Meier analysis. Results: We identified 600 pts. Median age was 65 (22-97 years). 71.2% (n=427) of pts had left sided CRC and 25.7% (n=154) had right sided Dx. 211 pts (35.2%) had de novo metastatic Dx. 163 of 389 pts (41.9%) with stage II/III disease relapsed. Median Dx-free interval was 16 months. Of 163 relapses, 121 (74%) were detected by radiologic surveillance and 14 (9%) by rise in CEA. Symptomatic relapse occurred in 20 pts (12%). Median overall survival (OS) was significantly improved in pts with relapse detected by CT, PET/CT or CEA rise (54, 53 and 54 months respectively) vs pts with symptomatic relapse (4 months, p<0.001). Metastasectomy rates were higher in pts with image-detected relapse ( p=0.017). Median OS for pts with stage IV CRC who received any Rx was 27 months. Pts with right sided Dx had shorter median OS vs pts with left sided Dx (24 months vs 40 months, p=0.002). 195 pts (52.8%) underwent metastasectomy; median OS was 71 months vs 16 months in those who did not undergo Sx. 84 pts (14%) with stage IV CRC are currently Dx-free after Sx. Median OS was improved with increasing lines of Rx. Survival in pts receiving best supportive care was 5 months vs 17, 25, 34, 38 and 42 months for pts receiving 2, 3, 4 and 5 lines of Rx respectively ( p<0.001). Conclusions: CRC outcomes are improving with effective multi-disciplinary care, close surveillance, sequencing of systemic Rx and judicious use of salvage Sx following relapse. Our findings support long-term benefit for surgical metatastectomy in stage IV CRC.

Selective Necrosectomy for Infected Pancreatic Necrosis

BACKGROUND

Until recently, a diagnosis of infected pancreatic necrosis (IPN) warranted necrosectomy, which was associated with high morbidity and mortality rates greater than 20%. Preoperative percutaneous drainage delayed the need for necrosectomy with improved outcomes.

METHODS

In 2008, this institution changed its approach to the management of such cases opting instead for percutaneous drainage with selective deferred necrosectomy. A total of 38 consecutive patients with IPN from January 2008 to December 2014 were included.

RESULTS

All 38 underwent percutaneous radiological drainage, and selective necrosectomy was performed on 15 where the infected necrosis did not completely resolve. Twenty-three patients did not require surgery and were managed with pancreatic drain insertion, optimal nutritional support and critical care interventions. Median peak Acute Physiology and Chronic Health Evaluation and Sequential Organ Failure Assessment scores were 10 (range 0-18) and 3 (range 0-10) prior to radiological intervention. Overall mortality was 5% (n = 2).

CONCLUSION

This study demonstrates that radiological-guided drainage of infected pancreatic collections can, in most cases, prove curative and, if not, facilitates delayed surgical intervention with improved outcomes.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Gloveport hernioscopy

It can be difficult to exclude occult, necrotic bowel in incarcerated herniae that reduce prior to emergent surgical exploration without resorting to further abdominal wall incisions. This case illustrates the Gloveport hernioscopy technique to identify necrotic small intestine that had spontaneously reduced in a man with a strangulated umbilical hernia. This minimally invasive technique allowed a multichannel examination of the peritoneal cavity without any further insult to the abdominal wall.

Pyogenic liver abscesses: diminished role for operative treatment

BACKGROUND

Pyogenic liver abscess is a rare but potentially serious condition. It has traditionally been treated by open drainage; however interventional radiology is now becoming the standard of care.

METHODS

All cases of liver abscesses admitted to a tertiary hospital over thirteen years (1995-2007) were retrospectively reviewed. Patient demographics, length of hospital stay, predisposing factors as well as cultured organisms were evaluated. Imaging techniques as well as patient management were also recorded.

RESULTS

There were 66 hospital admissions of 61 patients with liver abscesses, 0.032% (66/205,079) of the total hospital admissions for the time period. Mean age was 61 years (range 26-90 years), male (36/61) 59%: female (25/61) 41%. Average hospital stay was 23 days (Range 1-84 days) and there were no deaths. 39 of 61 patients (64%) had a single abscess (90% right lobe). 20 of 61 patients (33%) had undergone a recent intra-abdominal procedure. Escherichia coli (10/61) and Enterococci (8/61) were the most frequent organisms isolated. Radiological intervention was performed in 50 of 61 (82%, 51% ultrasound and 31% CT guided). 9 of 61 (15%) were managed conservatively, while one case was managed surgically and another with endoscopic sphincterotomy and stent placement.

CONCLUSIONS

Pyogenic liver abscesses are uncommon, and while associated with significant morbidity and prolonged hospital stay, mortality is now rare. Radiological intervention and anti-microbial therapy are the mainstay of treatment, and operative intervention is now rarely required.

Extension of hepatic necrosis secondary to current arcing to surgical clips: a potential complication of radiofrequency ablation

The authors present a case report of a 67-year-old woman who underwent radiofrequency ablation of recurrent hepatic metastases. She was managed 2 years previously with a right hemi-hepatectomy. Subsequent to RF ablation she developed hepatic necrosis extending in a linear fashion to two of the metallic surgical clips at the free edge of the liver, consistent with current arcing.

Giant solitary non-parasitic cyst of the liver

BACKGROUND

Cystic diseases of the liver and intrahepatic biliary tree are uncommon. The majority of cases are detected only when patients become symptomatic, or as an incidental finding on radiological imaging.

METHODS

We discuss the case of a 25-yr-old female with a centrally located giant liver cyst causing obstructive jaundice, and briefly discuss the management options in the treatment of this uncommon problem.

RESULTS AND CONCLUSIONS

Intervention is recommended in patients with symptomatic simple cysts of the liver. Surgical cystectomy is the treatment of choice for large deep seated cysts.

Long-term quality of life following pancreaticoduodenectomy

BACKGROUND/AIMS

This study examined long-term quality of life in an unselected consecutive cohort of patients undergoing pancreaticoduodenectomy, both Whipple and total, for benign and malignant disease.

METHODOLOGY

Forty consecutive patients who underwent pancreaticoduodenectomy over a nine-year period formed the study group. The control group consisted of 58 age- and sex-matched patients undergoing open cholecystectomy during the same period. Quality of Life was assessed using the European Organisation for Research and Treatment of Cancer QLQ-C30 (core cancer module) and QLQ-PAN26 (pancreatic cancer module) questionnaires at a median of 42 months postoperatively.

RESULTS

The Global Health Status of the study and control groups was similar, but significant differences were noted in certain individual scales. The benign group reported greater social and financial difficulties, and symptoms consistent with impaired exocrine function. The malignant group reported difficulties with daily physical and role functioning, concern for future health and individual symptoms such as fatigue, muscle weakness, and inability to gain weight.

CONCLUSIONS

This study demonstrates that the overall quality of life of patients who underwent pancreaticoduodenectomy compared favorably with that of a control group. Significant differences did exist in some individual scales, in both the benign and malignant sub-groups, suggestive of exocrine insufficiency.

Cystic duct remnant and the 'post-cholecystectomy syndrome'

Post-cholecystectomy syndrome refers to a wide spectrum of conditions that pose a challenging diagnostic dilemma. Cystic duct remnant, defined as a residual duct greater than 1 cm in length, may, in the presence of stones, cause post-cholecystectomy syndrome. In this report, 4 patients with post-cholecystectomy syndrome due to cystic duct remnant are described. All underwent laparoscopic cholecystectomy and one was converted to open. The patients presented with pain 10 months to 9 years post-cholecystectomy and investigations demonstrated cystic duct remnant. All patients underwent successful resection with resolution of symptoms. In this era of laparoscopic surgery, where surgery favors a long cystic duct remnant, we should be aware of cystic duct stones as a possible cause of postcholecystectomy syndrome. This report highlights magnetic resonance cholangiopancreatography as the optimal method for evaluating the biliary tract in these cases.

Intraperitoneal pethidine versus intramuscular pethidine for the relief of pain after laparoscopic cholecystectomy: randomized trial

Laparoscopic cholecystectomy is widely used and may be performed as an ambulatory procedure. We undertook a randomized comparison of the benefits of intraperitoneal pethidine compared with intramuscular pethidine for postoperative analgesia following laparoscopic cholecystectomy. A series of 100 consecutive American Society of Anesthesiologists (ASA) I or II patients were randomly assigned to intramuscular pethidine (54 patients) or intraperitoneal pethidine (46 patients). Each was combined with intraperitoneal bupivacaine. The primary endpoints were the pain and nausea scores at intervals after operation. All recruited patients completed the study. Pain scores at rest and upon movement were significantly lower in the group receiving the intraperitoneal pethidine at each of the time periods examined (pain at rest at 4 hours: 1.6 +/- 0.8 vs. 2.4 +/- 0.9 cm; p < 0.001; pain upon movement at 4 hours: 2.1 +/- 0.9 vs. 3.1 +/- 1.2 cm; p < 0.001). The total dose of pethidine administered via patient-controlled analgesia (PCA) during the first 24 hours after surgery was also significantly lower in this group (total dose 50.9 +/- 3.9 vs. 55.9 +/- 4.4 mg; p < 0.001). There were no significant differences in the respiratory rate at any of the time periods. Intraperitoneal pethidine analgesia was superior to an equivalent dose of intramuscular pethidine for the relief of postoperative pain in patients undergoing laparoscopic cholecystectomy. This was achieved at the expense of increased nausea but no significant increase in vomiting. The accessibility of this route of analgesia administration has implications for patients undergoing laparoscopic procedures, particularly with the recent trend toward increased use of ambulatory techniques.

Isolation of lymphocytes from normal adult human liver suitable for phenotypic and functional characterization

Murine and human studies have demonstrated that the normal liver contains significant numbers of resident lymphocytes that have functions distinct from those found in blood and other organs. To characterize these cells requires the isolation of viable lymphocytes that can be analysed by flow cytometry and in functional assays. The techniques classically used to isolate single cell suspensions of hepatic lymphocytes for phenotypic and functional studies involve mechanical and/or enzymatic dissociation of liver tissue. The aim of this study was to determine the effect of these procedures on surface molecule expression and lymphocyte function and to optimise an isolation technique that minimises these effects. Mechanical homogenisation of liver tissue alone resulted in low viable lymphocyte yields but these were improved by the combined use of mechanical and enzymatic techniques. A mean yield of 2.3 x 10(6) lymphocytes with a mean viability was 88.8% was obtained from 200 mg wedge biopsy samples of normal adult human liver using a combination of gentle mechanical dissociation followed by digestion with collagenase type IV and DNase I. These cells were suitable for phenotypic characterisation by flow cytometry. They also retained their ability to grow in vitro, to respond to cytokines and activation stimuli, to mediate cytotoxic killing of target cells, and to produce inflammatory and regulatory cytokines.

Gilmore's groin repair in athletes

Incapacitating groin pain is a frequent problem among athletes and its etiology may be multifactorial. A specific clinical syndrome relating to injury to the lower abdominal wall has been described and successfully treated by O. J. Gilmore. This paper presents our results of 100 consecutive groin repairs in 85 young athletes using a diagnostic and therapeutic strategy similar to Gilmore's. Ninety-six percent of our patients returned to competitive sport within 15 weeks; we suggest that this is an appropriate therapeutic intervention for athletes who develop chronic incapacitating groin pain.

Delayed correction of portal hypertension after portal vein conduit arterialization in liver transplantation

A 55-year-old woman underwent orthotopic liver transplantation for autoimmune chronic active hepatitis. Extensive portal and superior mesenteric venous thrombosis precluded standard portal venous reconstruction and necessitated use of a venous conduit from the recipient splenic vein of the donor liver. Flow through this conduit was poor, however, and to prevent subsequent portal venous thrombosis and graft loss, the conduit was arterialized by end-to-side anastomosis with the recipient hepatic artery. This ensured graft survival but resulted in prehepatic portal hypertension, which required ligation of the arterioportal fistula for 4 months. The patient had a satisfactory outcome.

Temporal relationship of acinar and microvascular changes in caerulein-induced pancreatitis

A study in rats investigated the temporal relationship between acinar cell changes and alterations in the local microvasculature in oedematous pancreatitis produced by administration of caerulein 5 micrograms kg-1 h-1. Samples were taken from experimental and control animals after 15 min, 30 min, 1 h and 2 h of caerulein infusion. Transmission electron microscopy showed ultrastructural acinar cell changes after 15 min whereas the earliest microvascular changes were seen after 30 min. Ultrastructural alterations in the acinar cells thus preceded local microvascular changes. Microvascular distortion appears to be a consequence and not a cause of pancreatitis in the caerulein model.

Microvasculature of the pancreas, liver, and kidney in cerulein-induced pancreatitis

Edematous pancreatitis was induced in 12 male Sprague-Dawley rats using supramaximal doses of the cholecystokinin analogue cerulein (5 micrograms/kg per hour). The microvasculature of the pancreas, liver, and kidney was examined using scanning electron microscopy of microvascular corrosion casts in 12 test animals and four controls at intervals of 30 minutes, 1 hour, 2 hours, and 4 hours. Distortion of the pancreatic and hepatic microvasculature was seen as early as 30 minutes and progressed during the study period. The renal vasculature remained normal throughout. Light microscopic analysis revealed no morphologic abnormalities in the walls of the pancreatic, hepatic, or renal microvasculature. This study demonstrates that cerulein-induced pancreatitis is associated with marked distortion of the pancreatic and hepatic microvasculature; the abnormalities start early in the disease and progress during the study period.

Relationship of nuclear DNA content to clinical and pathologic findings in patients with primary hepatic malignancy

BACKGROUND

Nuclear DNA content of a variety of tumors has proven valuable as a prognostic indicator. The purpose of this study was to analyze patterns of DNA content in primary hepatocellular carcinoma and to correlate ploidy status with patient survival.

METHODS

The relationship of nuclear DNA content to host and tumor characteristics was analyzed in 46 patients with primary hepatic malignancy who had undergone resection with curative intent between 1975 and 1985.

RESULTS

Flow cytometric measurement of tumor DNA content revealed a diploid pattern in 33%, tetraploid or polyploid in 30%, and aneuploid in 37% of cases. There was no significant correlation between tumor DNA content and demographic or pathologic findings in the patients studied. Moreover, there was no difference in survival between patients with diploid versus nondiploid tumors.

CONCLUSIONS

These findings suggest that tumor DNA content has no prognostic value in patients with primary hepatic malignancy.

Pulmonary microvasculature in experimental acute haemorrhagic and oedematous pancreatitis

The pulmonary microvasculature was examined in two experimental models of acute pancreatitis by scanning electron microscopy of microvascular corrosion casts. Haemorrhagic pancreatitis was induced in eight male Sprague-Dawley rats using an intraductal injection of 5 per cent sodium taurocholate. Oedematous pancreatitis was induced in seven male Sprague-Dawley rats using an intravenous infusion of supramaximal doses of caerulein (5 micrograms/kg per hour). The pulmonary vessels were cast using a polymer resin and the cast studied by scanning electron microscopy at 3 and 12 h in those with haemorrhagic and at 1 and 4 h in those with oedematous pancreatitis. Vascular abnormalities were present in both models at the initial study time with abruptly terminating vessels being more prominent in the caerulein model. At the later times, however, the abnormalities in the sodium taurocholate model were much more severe, with a substantial loss of vascular density, tortuosity and abrupt terminations of those vessels present. Microvascular abnormalities may be responsible for some of the pulmonary changes seen in oedematous and haemorrhagic pancreatitis.

Radical resection for carcinoma of the ampulla of Vater

One hundred four consecutive patients who underwent radical resection for ampullary cancer between 1965 and 1989 were retrospectively reviewed. Frequent clinical findings included jaundice (67%), significant (greater than 10%) weight loss (42%), and anemia (27%). Eighty-seven patients (84%) underwent a subtotal pancreatectomy, and 17 patients (16%) underwent a total pancreatectomy. The postoperative mortality was 5.7% (six patients), and reoperation for postoperative complications was required in six patients. The 5- and 10-year survival rates were 34% and 25%, respectively. Eight patients died of tumor recurrence more than 5 years after resection. Patient survival was significantly impaired by microscopic lymphatic invasion, regional nodal metastasis, tumor grade, and the epithelium of origin. In a multivariate analysis, only microscopic lymphatic invasion significantly reduced patient survival. Radical resection for ampullary cancer can be performed with a low morbidity and mortality and should remain the procedure of choice for ampullary carcinoma.

Cytoreductive hepatic surgery for neuroendocrine tumors

We retrospectively reviewed 37 patients who underwent hepatic resection between 1970 and 1989 to evaluate the role of cytoreductive hepatic surgery in patients with metastatic neuroendocrine tumors (carcinoid, 24; islet cell, 13). Seventeen resections were curative (no gross residual tumor); nine patients had symptomatic endocrinopathies and seven patients had symptoms caused by the primary tumor. Eight of nine patients with symptomatic endorcrinopathies obtained complete relief of symptoms; five are alive with no evidence of disease at 2 to 82 months (mean, 26 months). Six of seven patients with symptoms caused by the primary tumor obtained complete relief; five are alive with no evidence of disease at 5 to 28 months (mean, 14 months). One symptom-free patient underwent curative hepatic resection 5 years after abdominoperineal resection for a rectal carcinoid. Twenty resections were palliative (gross residual tumor); 16 patients had symptomatic endocrinopathies and 4 patients had symptoms caused by the primary tumor. Eight of 16 patients with symptomatic endocrinopathies obtained complete relief; five are alive at 2 to 30 months (mean, 11 months), with a mean duration of complete relief of 6 months (3 to 12 months). All four patients who underwent resection for symptoms caused by the primary tumor obtained complete relief; two are alive and symptom free at 10 and 101 months. Our experience suggests that curative surgery should be considered in all patients with completely resectable metastatic disease and that palliative surgery, despite the short duration of complete relief, should be considered in selected patients because it delays and may reduce the subsequent need for medical therapy.

Experimental study of starch-induced intraperitoneal adhesions

The effects of starch on the development of postoperative adhesions were examined in 144 Sprague Dawley rats. Groups of rats were injected intraperitoneally with suspensions of washings from starched gloves, starch-free gloves and starch-poor washed gloves, and after operative manipulation of the bowel. The incidence of adhesions was greatest (78 per cent) after laparotomy and injections of starch-rich washings and least when starch-poor (33 per cent) or starch-free glove suspensions (37 per cent) were used, confirming an advantage for washing gloves or switching to starch-free products.

Surgical audit of patients undergoing common bile duct exploration for stone

One hundred and sixty-four patients operated on for calculus disease of the common bile duct during the period 1977-85 were followed in a special clinic; the attendance for follow-up at 1, 3, 5 and 7 years was 90, 74, 60 and 54 per cent respectively. Eleven patients died during the study period (6.7 per cent), none of the deaths being attributable to biliary tract disease. The overall incidence of retained calculus was 2.4 per cent (four patients), but no cases of retained calculi were recorded in the last 4 years of the study; in this period, with the advent of choledochoscopy and fluoroscopic cholangiography, the incidence of the supraduodenal compared with the transduodenal approach to the common bile duct increased significantly (P less than 0.001). Twenty-two of 56 patients (39 per cent) followed up for 5 years remained or became symptomatic after surgery, the majority of whom had underlying conditions unrelated to disease of the biliary or pancreatic tree. This specific follow-up clinic has been of value in the long-term audit of patients undergoing bile duct surgery for choledocholithiasis and it has verified that a change of policy from transduodenal to supraduodenal choledochotomy with preservation of the sphincter, and use of the choledochoscope and fluorocholangiography, produce better results.

Timing of strangulation in adult hernias

This retrospective study aimed to determine why the incidence of strangulated hernias in adults remains high. Seventy-nine patients presented with clinical evidence of hernia strangulation which required urgent surgery during the period 1979-87. Forty-six patients (58 per cent) had noted a hernia present for at least 1 month before strangulation: 18 (23 per cent) had not reported it to their family doctor, 19 (24 per cent) were known by family practitioners or non-surgical medical personnel to have a hernia but had not been referred for surgical opinion, and nine (11 per cent) had been previously assessed surgically with a view to elective repair. Of these nine, five were considered unfit, three were on waiting lists for operation and one had refused surgery. Thirty-two patients (40 per cent) presented primarily with strangulation within days of developing a hernia. The duration of hernia before strangulation in one patient was unknown. Although an unavoidable number of patients will continue to present with strangulation within days of developing a hernia, the overall incidence could be significantly reduced by greater public awareness of the risks of hernia strangulation and by a policy of immediate patient referral and prompt elective repair.

The role of CT in the management of carcinoma of the oesophagus and cardia

The role of computed tomography in assessing tumour spread and tumour resectability was evaluated in 50 patients with oesophageal carcinoma (17 middle third, 33 lower third). CT accurately identified all patients with tumour confined to the oesophagus (Stage I or II) but was limited in its ability to assess direct organ invasion (Stage III) with an overall accuracy for evaluating middle third lesions of 82% (aorta 70%, tracheobronchial tree 94%, other mediastinal structures 82%) compared to an overall accuracy for lower third lesions of 97% (aorta 97%, pancreas 100%, diaphragm 97%). Tumours deemed resectable on CT were always resectable at operation but two of seven middle third tumours and one of twelve lower third lesions deemed unresectable underwent curative resection. Preoperative CT evaluation of oesophageal tumours is useful in that it may reliably identify tumour lesions confined to the oesophagus and reliably identify distant metastases. Because of its limitations however in the assessment of organ invasion, particularly by middle third lesions, this study suggests that patients with oesophageal tumours with no evidence of distant metastases, who are otherwise fit to undergo tumour resection, should not be denied surgery on the sole basis of positive organ invasion on CT particularly if that organ is the aorta.

Alcohol induced pancreatitis: social and surgical aspects

During the period 1977-1985, 38 patients with alcohol related pancreatitis (37 men, 1 woman) were referred to a specific pancreatic follow-up clinic; their mean age was 42.4 years (range 20-69 years). At initial presentation 14 patients were unemployed (37 per cent) and 11 worked as unskilled labourers (29 per cent). Twenty-seven patients (71 per cent) required more than one hospital admission. Surgery was indicated in 14 patients (37 per cent): 4 diagnostic laparotomy, 3 cholecystectomy, 3 drainage of pancreatic pseudocyst and 1 pancreatic abscess, 3 biliary bypass and 4 pancreatic resection. Four patients required more than one operative procedure. Five deaths occurred during the study period: one following biliary bypass, one following total pancreatectomy and three not directly related to pancreatitis. Follow-up attendance rates at 1, 3 and 5 years were 76, 47 and 34 per cent respectively. Alcohol induced pancreatitis in Teesside, UK, is a disease of young adult males of lower socio-economic status with a recurring pattern leading to repeated hospital admissions and an unexpectedly high incidence of surgery. The study demonstrates the problem of ascertaining data related to long term follow-up in a condition where, despite intensive efforts, patient compliance is poor.

Single dose antibiotic prophylaxis in high risk patients undergoing transurethral prostatectomy

In a randomized controlled clinical trial single dose antibiotic prophylaxis (gentamicin 80 mg IV) was evaluated in 36 patients with indwelling urethral catheters undergoing transurethral prostatic resection. Prophylaxis resulted in a significant reduction in postoperative bacteriuria (P less than 0.01), pyrexia (P less than 0.001), bacteraemia (P less than 0.01) and septicaemia (P less than 0.05). During the same period there was one case of postoperative bacteriuria but no systemic infection in 25 consecutive patients undergoing elective prostatectomy with no local risk factors and in the absence of prophylaxis. A policy of selective antibiotic prophylaxis is justified and in high risk patients with in-dwelling catheters single dose prophylaxis is highly effective.

Sialography in salivary gland disease

Ninety-six consecutive patients underwent sialography over a 10 year period at North Tees District General Hospital; there were 68 parotid and 28 submandibular examinations. Patients were divided into two groups: group 1, patients with symptoms but no clinical signs (n = 27); group 2, patients with swelling of the salivary gland (n = 69). Results showed that sialography was of considerable value in group 1 patients demonstrating pathology in 33 per cent (9/27 patients). In patients with a suspected, but unusually situated, parotid tumour (n = 20) sialography was confirmatory in 10 patients but the technique failed in four, gave a false negative result in four and would seem to be of limited value. In the remaining patients in group 2 with diffuse glandular swelling (n = 49) the main contribution of sialography was in demonstrating sialectasia (9), duct strictures (4) and non-opaque parotid calculi (2), but even in this group of patients 35 per cent (17/49 patients) of the examinations were normal. When submandibular calculi were demonstrable on plain radiography sialography contributed no further relevant information.